Case
Reports
Vedran Radonic, ´ MD, PhD
´ MD
Stevan Koplic,
Lovel Giunio, MSc, MD
Ivo Božic,
´ MSc, MD
Josip Maškovic,´ MD, PhD
´ MSc, MD
Ante Buca,
Key words: Angiography,
digital subtraction; popliteal
artery/surgery; popliteal
artery entrapment syn-
drome; tomography, x-ray
computed; ultrasonography,
Doppler, duplex
From: The Departments of
Surgery (Drs. Radonic´ and
Koplic),
´ Internal Medicine
(Drs. Giunio and Božic),
´ and
Radiology (Drs. Maškovic´
and Buca),
´ University
Hospital, Split, Croatia
Address for reprints:
Vedran Radonic,´ MD,
Department of Surgery,
University Hospital,
Split, Spinciceva
V
´ 1,
21 000 Split, Croatia
© 2000 by the Texas Heart ®
Institute, Houston
Texas Heart Institute Journal
Popliteal Artery
Entrapment Syndrome
Diagnosis and Management,
with Report of Three Cases
Popliteal artery entrapment syndrome is an important albeit infrequent cause of serious
disability among young adults and athletes with anomalous anatomic relationships
between the popliteal artery and surrounding musculotendinous structures. We report
our experience with 3 patients, in whom we used duplex ultrasonography, computed
tomography, digital subtraction angiography, and conventional arteriography to diagnose
popliteal artery entrapment and to grade the severity of dynamic circulatory insufficien-
cy and arterial damage.
We used a posterior surgical approach to give the best view of the anatomic struc-
tures compressing the popliteal artery. In 2 patients, in whom compression had not yet
damaged the arterial wall, operative decompression of the artery by resection of the
aberrant muscle was sufficient. In the 3rd patient, operative reconstruction of an occlud-
ed segment with autologous vein graft was necessary, in addition to decompression of
the vessel and resection of aberrant muscle. The result in each case was complete re-
covery, with absence of symptoms and with patency verified by Doppler examination.
We conclude that clinicians who encounter young patients with progressive lower-
limb arterial insufficiency should be aware of the possibility of popliteal artery entrap-
ment. Early diagnosis through a combined approach (careful physical examination and
history-taking, duplex ultrasonography, computerized tomography, and angiography) is
necessary for exact diagnosis. The treatment of choice is the surgical creation of normal
anatomy within the popliteal fossa. (Tex Heart Ins J 2000;27:3-13)
D
espite technical advances in arterial repair, trauma to the popliteal artery
continues to be associated with a relatively high amputation rate in most
civilian and military experiences.1-4
One rare popliteal arterial lesion is popliteal artery entrapment syndrome
(PAES). This anomaly usually affects young men (aged 20 to 40 years) as the most
common of several unusual entities that cause intermittent claudication in young
adults. The other causes of acute vascular insufficiency of the limb in young per-
sons are premature accelerated atherosclerosis, thromboangiitis obliterans, adventi-
tial cystic disease, adductor canal outlet syndrome, microemboli, collagen vascular
disease, Takayasu’s arteritis, and coagulopathy. 5-7
Popliteal artery entrapment syndrome is a consequence of abnormal positioning
of the popliteal artery in relation to its surrounding structures. In type I entrapment
(Heidelberg classification system), the popliteal artery has an atypical course; in
type II, the muscular insertion is atypical; and in type III, both conditions are pre-
sent.8 These abnormal anatomic relationships can produce extrinsic compression of
the popliteal artery and cause vascular damage.9-12 Eventually, an irreversible lesion
of the popliteal artery can manifest itself as aneurysmal dilatation, thrombosis, or
embolism and can result in ischemia, threatening limb viability. Diagnostic delay is
common because this problem usually occurs in young, athletic patients, who lack
the vascular conditions that would predispose them to atherosclerosis and limit their
normal social and professional activities in the presence of even mild symptoms.
Most commonly, PAES is found in young sportsmen or soldiers with well-devel-
oped muscles,13-15 because the exercise and enlargement of muscles adjacent to the
popliteal artery exacerbates the consequences of the anomalous relationship between
muscle and artery. Therefore, military surgeons have taken a special interest in this
disorder, which has increased the diagnostic rate of PAES in military personnel.16-18
Popliteal Artery Entrapment Syndrome 3
 Patients and Methods
Three patients with popliteal artery stenosis or oc-
clusion secondary to entrapment are described in
this study. Before surgery, all patients underwent
assessment that included Doppler ultrasonography,
computerized tomography, and conventional arteri-
ography or digital subtraction arteriography.
Duplex ultrasonographic scans were performed us-
ing an ATL Ultramark 9 duplex scanner (Advanced
Technology Laboratories; Bothell, Wash). Popliteal
arteries were examined by means of a 5-MHz trans-
ducer, with the patient in a prone position while the
knee was fully extended, and in neutral position.
Diagnostic maneuvers consisted of actions causing
gastrocnemius muscle contraction. Such maneuvers
included active ankle extension and passive dorsiflex-
ion of the foot, and knee hyperextension. Arterial
flow signals were identified using continuous-wave
Doppler at the popliteal artery. After identification of
the artery, the Doppler system was switched to the
pulsed-wave mode and was guided by the flow pro-
file; midstream signals were recorded on a Technics
RS-B48R tape recorder. As a basis of comparison, we
used Doppler waveforms with the least dampened sig-
nals from the contralateral popliteal artery.
Contrast-enhanced computed tomographic (CT)
scanning has proved valuable in the diagnosis of
PAES. The first 2 patients were scanned with the So-
matom DR G (Siemens AG; Erlangen, Germany);
the 3rd patient was scanned with the SCT-4800 TF
Intelect (Shimadzu; Osaka, Japan). All scans were
performed using continuous 10-mm slices (3-second
scan time, 6-second intersection delay). Scanning was
performed immediately after a manual bolus injec-
tion of nonionic contrast medium (iohexol 350, 40
mL) and during continuous infusion (at a rate of 20
mL/min) of an additional 60 mL of the same con-
trast agent. Scanning was limited to a 12- to 15-cm
region of the popliteal area, from 8 cm above to 7 cm
below the femoral junction. Helical parameters in-
cluded 5-mm collimation, 5-mm/s table speed (1.0
pitch), and 5-mm-thick image reconstruction. The
reduction in diameter of the artery was used for grad-
ing the stenosis, and the diameter of the area of the
most severe arterial reduction in any plane was com-
pared with the diameter of the most-normal-looking
segment proximal or distal to the stenosis, or with the
diameter of a normal segment from the other leg.
Multiplane reformations were routinely performed to
analyze the popliteal arteries in more detail. Final
interpretation was based upon the data provided by
analysis of the combination of axial transverse sec-
tions and multiplane reformation images.
Diagnostic arteriography was performed by the
Seldinger technique, via the transfemoral approach.
4 Popliteal Artery Entrapment Syndrome
The arteriograms were examined to determine the
presence or absence of popliteal artery stenosis
(>50% reduction in diameter), to determine if there
were signs of extrinsic compression of the popliteal
artery by adjacent structures, and to determine if the
course of the artery was abnormal. Arteriography
with the foot in a neutral position was compared
with arteriography during active plantar extension
of the foot for assessment of compression of the
artery in the popliteal fossa. Intra-arterial digital
subtraction angiography (DSA) or conventional
angiography was used routinely. Arteriography was
performed with a single-plane Siemens imaging sys-
tem (Erlangen, Germany).
Case Presentations and Follow-Up
Case 1
In September of 1995, a 31-year-old bus driver pre-
sented with a complaint of right calf pain, which he
had experienced occasionally during the preceding 2
months and which intensified during ambulation or
other exertion. He smoked 1 pack of cigarettes daily.
Physical examination revealed an athletic young man
in sinus rhythm, with a pulse rate of 65/min and a
blood-pressure reading of 120/80 mmHg. Right
pedal pulses were reduced with the knee in the neu-
tral position and disappeared completely with the
knee hyperextended. Doppler sonography showed
normal right popliteal artery morphology and good
flow with the knee in the neutral position (Fig. 1A).
Active plantar extension against resistance and pas-
sive dorsiflexion of the foot compressed the popliteal
artery and reduced blood flow (Fig. 1B). A CT scan
on the level of the femoral condyles and the proxi-
mal 3rd of the calf showed localized stenosis of the
right popliteal artery between the femoral condyles.
Scans at the level of the intercondylar fossa showed a
2.5-cm segment of the right popliteal artery to be
flattened like a sword sheath (Fig. 1C), while at the
level of the upper margin of the joint surface of the
tibia (that is, in the fossa poplitea) a ca. 2-cm seg-
ment of the right popliteal artery was compressed by
the hypertrophic medial head of the gastrocnemius
muscle (Fig. 1D). The axial transverse and the mul-
tiplane reformation images demonstrated extrinsic
compression of the right popliteal due to an anom-
alous insertion of the aberrant head of the gastrocne-
mius. A functional angiogram of the right popliteal
artery in active flexion did not reveal pathomorpho-
logic changes (Fig. 1E), but a ca. 2-cm segment of
the artery was seen to be narrowed in active exten-
sion, and a 1-cm-wide, beam-like extrinsic compres-
sion was seen before the trifurcation (Fig. 1F).
During surgical intervention, we resected the ac-
cessory head of the gastrocnemius muscle, liberating
Volume 27, Number 1, 2000
 A B
C D
E F
Texas Heart Institute Journal
Fig. 1 Case 1: A) Doppler sono-
gram shows normal popliteal
artery flow (vertical arrow) with
knee in neutral position. B) Doppler
tracing of popliteal artery flow with
knee hyperextended during plantar
extension of the foot shows mono-
phasic configuration of the velocity
waveform, with a blunt and
rounded peak (vertical arrow) that
suggests minor arterial stenosis.
C) Computed tomographic scan
performed after intravenous
injection of contrast material
shows enlarged medial head of
gastrocnemius muscle joined with
the accessory head (white arrow),
and the normal lumen of the artery
(black arrow). D) Computed tomo-
graphic scan with knee extended
shows compression of artery
(black arrow) by the accessory
head of gastrocnemius muscle
(white arrow). E) Arteriogram
shows normal right popliteal artery
(white arrow) with knee in the
neutral position. F) Arteriogram of
the hyperextended right knee
shows constriction of the popliteal
artery at the site of entrapment
(white arrow).
Popliteal Artery Entrapment Syndrome 5
the right popliteal artery. Postoperative necrosis of
the skin on the margins of the operative wound
necessitated a free-skin transplant graft. The subse-
quent postoperative course was uneventful and the
patient was discharged in 3 weeks. A follow-up ex-
amination twelve months later showed normal pop-
liteal artery patency.
Case 2
In June of 1994, a 33-year-old skilled mechanic was
referred because of intermittent right-calf claudica-
tion, accompanied by coldness, numbness, and
blanching of the foot. Symptoms were precipitated
by walking 400 meters, were relieved by a short rest,
and disappeared completely 1 hour after ambulation.
Similar symptoms occurred while driving a car for 1
hour or more. These difficulties had 1st appeared 4
years before presentation, had been continual during
the preceding 2 years, and had markedly worsened
during the preceding week. The patient was a non-
smoker and non-drinker who had kept active for 15
years by boxing, running, and weight-lifting.
Physical examination revealed an athletic young
man, 85 kg in weight, 180 cm in height, in sinus
rhythm, with a pulse rate of 75/min and a blood-
pressure reading of 125/80 mmHg. In the lower
limbs, there were no skin or temperature changes.
All pulses were palpable in the neutral position.
With the knee extended, no pulse could be detected
in the popliteal artery or in the dorsalis pedis and
posterior tibial arteries of the right foot.
Electromyography showed a minor loss of moto-
neurons in the small muscles of the right foot and in
the anterior muscle group of the right lower leg.
Doppler sonography did not show any abnormality
of the popliteal artery while the knee was in neutral
position (Fig. 2A), but with the knee extended it re-
vealed highly phasic, staccato waveforms (Fig. 2B),
suggesting stenosis.
Dynamic CT scanning of the popliteal fossa, per-
formed in a 4-mm scan with intravenous bolus
administration of contrast medium during a submax-
imal calf muscle contraction and plantar extension of
the foot, showed an accessory medial head of the gas-
trocnemius muscle compressing the right popliteal
artery (right leg is visible on the left side in Fig. 2C);
images in the sagittal plane depicted the narrowed
vascular lumen of the right popliteal artery (Fig. 2D).
Digital subtraction angiography performed with
the knee in the neutral position yielded a normal
radiographic finding (Fig. 2E), but during extension
at the knee and active full plantar extension at the
ankle, the popliteal artery appeared to discontinue
near the joint fissure, and flow through the vessel
was markedly slow (Fig. 2F). In flexion, the flow was
normal (Fig. 2G).
6 Popliteal Artery Entrapment Syndrome
Upon surgery, we used the posterior approach and
found that the accessory head of the gastrocnemius
muscle was inserted abnormally into the medial
condyle. The popliteal artery was angulated and
trapped behind the muscle. Below and above the site
of compression, the wall of the popliteal artery and
its internal diameter were normal. Myotomy was
then performed. Postoperatively, the right dorsalis
pedis and posterior tibial pulses become palpable in
all positions. The patient had an uneventful postop-
erative course and was discharged home on the 6th
postoperative day. At follow-up examinations after
discharge, the patient complained of numbness on
the medial aspect of his right leg.
Case 3
In October of 1997, a 21-year-old lorry driver com-
plained of progressively increasing right-leg calf clau-
dication. The pain and numbness in the right lower
leg had started suddenly after swimming, 3 months
before his referral. His pain-free walking distance
was 100-200 m. He was smoking about 20 cigarettes
daily. He had been playing amateur soccer as a de-
fensive player for 4 years.
Physical examination revealed a muscular young
man, 78 kg in weight and 175 cm in height, with a
pulse rate of 70 per min and a blood-pressure read-
ing of 120/80 mmHg. No pulses were palpable in
the right leg below the popliteal fossa. The time
required for restoration of color after application of
finger-pressure to the skin was normal in both legs,
and there were no morphologic changes.
Two-dimensional and Doppler sonographic im-
ages of the left popliteal artery showed normal flow
(Vmax 0.7 m/s) and diameter (Fig. 3A), while 2-D
images on the right showed the proximal popliteal
lumen but lost the distal lumen. No Doppler signal
of arterial flow could be obtained on the right, which
suggested complete interruption of arterial circula -
tion (Fig. 3B).
A dynamic CT scan with intravenous bolus con-
trast enhancement (Fig. 3C) at the level of the pop-
liteal fossa demonstrated occlusion of the right
popliteal artery due to muscle entrapment by the 3rd
head of the gastrocnemius muscle (Fig. 3D).
Digital subtraction angiography of the right leg
showed a long occlusion (12 cm) of the popliteal
artery and many unobstructed collateral vessels (Fig.
3E). Above the trifurcation, the circulation was
established by well-developed collateral flow (Fig.
3F), which suggested that the occlusion was old.
At operation, the popliteal artery was seen to be
completely occluded and to course below the 3rd
head of the gastrocnemius muscle. The compromised
arterial segment was replaced by an autologous ve-
nous graft, and the 3rd head of the gastrocnemius
Volume 27, Number 1, 2000
A B

C D

E F G

Fig. 2 Case 2: A) Doppler ultrasonographic image of right popliteal artery flow (vertical arrow) with knee in normal position shows
no abnormalit y. B) Doppler tracing of popliteal artery flow (vertical arrow) with knee hyperextended during plantar extension of the
foot reveals highly phasic, staccato waveforms, which suggest high-grade distal arterial stenosis. C) Axial dynamic computed
tomographic scan with intravenous contrast enhancement during a submaximal calf muscle contraction demonstrates accessory
head of the gastrocnemius muscle (white arrow) compressing small-caliber right popliteal artery (black arrow), in comparison with
the opposite normal-caliber left popliteal artery (arrow). D) Phase-contrast images in sagittal plane depict flow in the popliteal artery
during a submaximal calf muscle contraction. The vascular lumen is narrowed from side to side and flow signal intensity is declined
in the sagittal aspect over a 3-cm length below the knee (white arrow) during plantar extension of the foot. Note the relationship
between the popliteal artery and the abnormally inserted accessory head of the gastrocnemius muscle. E) Right transfemoral
digital subtraction angiogram shows normal popliteal artery flow (black arrow) with knee in neutral position. F) Severe stenosis of
the popliteal artery (black arrow) with full extension at the knee and active plantar extension at the ankle. G) Normal popliteal artery
flow (white arrow) with foot in passive dorsiflexion.

Texas Heart Institute Journal Popliteal Artery Entrapment Syndrome 7

A B

C D

E F
Fig. 3 Case 3: A) Duplex sonogram waveform from a normal left popliteal artery demonstrates a rapid early rise in systole.
B) Duplex sonogram from right popliteal artery shows complete occlusion (vertical arrow) and no Doppler signal. C) Dynamic
computed tomographic scan with intravenous contrast enhancement demonstrates thrombosis of the right popliteal artery
(black arrow), in contrast with patent left popliteal artery (white arrow). Accessory head of the right gastrocnemius muscle
(white arrowhead) is clearly demonstrated, in contrast with normal anatomic relationships seen in left limb. D) Phase contrast
computed tomographic images in sagittal plane depict increased mass of the 3rd head of the gastrocnemius muscle in the right
leg (arrowheads). E) Digital subtraction arteriogram demonstrates a complete segmental occlusion of the right popliteal artery
(arrow). Note the absence of atherosclerotic signs in the collateral arteries. F) The length of the occluded segment was 120.6 mm
(white line). G) Control postoperative Doppler ultrasonogram demonstrates patent saphenous vein in situ bypass (arrowheads)
between the proximal and distal portions of the popliteal artery.

8 Popliteal Artery Entrapment Syndrome Volume 27, Number 1, 2000

muscle was resected. The patient no longer experi-
enced any impairment upon walking, and repeat
Doppler ultrasonography showed unimpeded flow
through the graft, even on plantar extension (Fig.
3G).
Discussion
In 1879, while still in medical school at Edinburgh,
Anderson Stuart became the 1st to describe the
anatomical basis of popliteal entrapment. 19 In 1925,
Chambardel-Dubreuil described a case in which the
popliteal artery was separated from the popliteal vein
by an accessory gastrocnemius muscle.20 Hamming
and Vink, in 1959, performed the 1st operative de-
compression of an entrapped popliteal artery, at
Leyden University in the Netherlands. 21 The 1st case
diagnosed before surgical intervention was reported
by Servello in 1962, at the University of Padua in
Italy. 22 Love and Whelan, of Walter Reed General
Hospital in the United States, introduced the term
“popliteal artery entrapment syndrome” (PAES) in
1965.16 Popliteal artery entrapment syndrome is an
uncommon cause of lower-extremity claudication,
which usually occurs in younger patients who lack
the risk factors for atherosclerosis and who are
healthier and more active than average for their age
group. Most of them are sportsmen, and some play
professionally. The most frequently involved activi-
ties are team sports (such as soccer, rugby, and bas-
ketball) and martial arts. All of these activities
require repeated sudden and forceful contraction of
the calf, which results in hypertrophy of the calf
muscles. Similar contraction can cause PAES in
heavy-vehicle drivers, such as military personnel
who drive armored vehicles. 15
Popliteal artery entrapment syndrome occurs
when these conditions exist: 1) an abnormal ana-
tomical relationship between the popliteal artery
and the surrounding musculotendinous structures;
2) hypertrophy of the musculotendinous structures;
and 3) repeated arterial compression upon exercise.
These anatomic variants of PAES have been pro-
posed: atypical course of the popliteal artery from
the medial or lateral head of the gastrocnemius mus-
cle; compression of a normally running artery by
anomalous musculotendinous formations lying be-
tween the 2 gastrocnemius heads (usually compres-
sion by the aberrant head of the gastrocnemius, or
compression by the excessively hypertrophied soleus,
plantaris, or popliteus muscle); or a combination of
a dislocated artery and muscular abnormalities.23-34
As of 1999, over 450 cases of PAES had been report-
ed in the medical literature.35,36 Uncommonly, the
popliteal vein, rather than the popliteal artery, is
involved. 11,37-46
Texas Heart Institute Journal
Changes in the popliteal artery associated with ex-
ternal compression have ranged from post-stenotic
dilatation to true aneurysm formation. Thrombosis
has also occurred at the site of entrapment. This
localized area of thrombosis is usually found in the
mid-popliteal artery, and extensive collateral devel-
opment is frequently present.47-49
Because PAES is both uncommon and difficult to
diagnose, it poses a diagnostic pitfall. Awareness of
the entity is of course a prerequisite for correct
diagnosis. Of utmost importance are a careful histo-
ry and a careful physical examination. The charac-
teristic signs and symptoms are a history of leg
swelling, aching pain, pain at rest, and tiredness or
cramping of the calf; but symptoms can vary and,
until complications develop, physical signs are
absent at rest. In the early stages, when the artery is
patent except during calf-muscle contraction, symp-
toms in young persons are usually limited to transi-
tory cramps or a feeling of coldness. Patients may
report numbness, blanching, coldness, or cramps of
the limb in a variety of postures, which usually
resolve with a change of position. The onset of the
symptoms is often sudden, during intense physical
exercise. Early in the course of entrapment syn-
drome, a provocative test is needed for diagnosis: the
patient is asked to hyperextend his leg and to con-
tract the gastrocnemius muscle by means of active
plantar extension or maximal passive dorsal flexion,
which should lead to a decrease or disappearance of
pulses of the foot. 50
In the later stages of undiagnosed PAES, when the
artery is affected by stable lesions (local stenosis or
occlusion, local thrombotic interruption, or post-
stenotic aneurysm) typical symptoms are severe
acute ischemia and intermittent calf claudication,
usually monolateral. Such symptoms are surprising
when they occur in healthy-looking young subjects
who lack atherogenic risk factors. Acute ischemia
occurs as a result of thrombosis in situ and is com-
mon in young patients who have not developed suf-
ficient collateral circulation.51,52 The high proportion
of patients who are drivers of lorries, buses, or mili-
tary vehicles may be a consequence of their sitting
with an acutely flexed knee and of their repeatedly
alternating forced plantar extension with forced
plantar flexion, which can result in calf-muscle
hypertrophy.
Extensive efforts have been made to diagnose
PAES by noninvasive means. Duplex sonography of
the compressed popliteal artery is a noninvasive,
quick, and relatively inexpensive test. The popliteal
artery is ideally situated for ultrasonographic exami-
nation, and the effect of dynamic maneuvers can be
assessed with Doppler examination. Popliteal arterial
stenosis can be quantified by measuring the peak
Popliteal Artery Entrapment Syndrome 9
systolic velocity (PSV) ratio across a lesion: the PSV
within a stenosis is compared with that in a disease-
free popliteal segment in the opposite limb, and a
ratio is created that is independent of individual
variations in blood pressure, vascular compliance,
and cardiac function. We defined a significant steno-
sis as one with a PSV ratio greater than 2. Tur-
bulence with aliasing of the signal is required to
diagnose hemodynamically significant stenosis. Ves-
sels were considered to be occluded if no flow could
be detected by such means as DSA and no pulsatile
flow could be detected by pulsed Doppler. The op-
posite limb is always screened as well, because the
syndrome is bilateral in up to two-thirds of all cases.
However, mapping both legs of a patient requires
about 60 to 90 minutes.
One purpose of our study was to adopt duplex
imaging as the primary diagnostic technique for
popliteal artery entrapment, because the superficial
location of the popliteal artery renders it easily acces-
sible for ultrasound examination. The present results
show that duplex imaging may be useful as the pri-
mary investigational tool in the early diagnosis of
PAES. Duplex ultrasonographic scanning is the 1st
diagnostic tool that has the ability, through intensive
graft surveillance, to provide clear anatomical and
functional data about the quality of peripheral by-
pass grafts. Follow-up monitoring of bypass grafts
with duplex scanning, after decompression and re-
section of an occluded segment of an artery, is an
almost ideal screening procedure, because of its sim-
plicity and noninvasive character. 53-56 Ultrasonogra-
phy, however, lacks the image clarity for accurate
analysis of soft-tissue structures.
Computed tomography of PAES is a new diag-
nostic approach that has been made possible by im-
provements in CT-scanner technology. The main
advantage of the CT scan arises from its capacity to
view the 3-dimensional model from any angle after
data acquistion in order to best visualize soft-tissue
anatomy—in our case, the position of the artery in
relation to that of the surrounding muscles. Careful
analysis of axial scans on the monitor enables ac-
curate grading of popliteal arterial stenoses and evalu-
ation of surrounding muscular anomalies. Once
images are loaded at the workstation, axial scans can
be viewed rapidly by scrolling up and down the
vascular tree. Interpretation of axial scans on the mon-
itor also enables electronic enlargement of each af-
fected leg segment and rapid changing of window
parameters. When axial CT scans are interpreted,
diagnostic errors caused by the superimposition of
overlying structures such as bone are avoided by
increased versatility of image postprocessing. Lateral
and oblique views of CT images are useful for detec-
tion of arterial deviation and aberrant muscle, but
10 Popliteal Artery Entrapment Syndrome
axial slices provide the most accurate view. Com-
puted tomography may be more accurate than digital
subtraction angiography, due to its multiplane re-
construction capabilities. The speed of current CT
scanners enables dynamic imaging during peak bolus
contrast enhancement. The inherent high contrast
available with CT—along with its ability to recon-
struct sans the superimposition of overlying struc-
tures—yields excellent visualization of normal,
stenosed, and thrombosed vascular lumen. For ac-
utely ischemic limbs, it is of major importance to
know the site and origin of vascular occlusion and the
degree to which distal vessels are being refilled.
Therefore, the accuracy of CT in imaging acute dis-
ease should be at least as high as that in imaging
chronic disease. For the acutely ischemic leg, CT may
provide important information not provided by DSA,
such as the presence of aberrant muscle, the relation-
ship between the popliteal artery and surrounding
structures, and information about other conditions
affecting the popliteal artery, such as cystic adventitial
disease and thrombosed popliteal artery aneurysm.
Computed tomography can detect occlusion, devia-
tion, and stenosis of the popliteal arteries. It can be
diagnostic when arteriography is not helpful (for
example, in a case of late-stage PAES with throm-
bosed artery), and it can confirm normal contralateral
anatomy, thereby eliminating suspicion of bilateral
entrapment. 57-63 The major limitations of current CT
technology are attributable to limited tube capacity.
Traditionally, contrast arteriography, preferably bi-
lateral, has been considered the definitive test. The
following angiographic signs can be observed: inter-
nal deviation, flatness or a clinched appearance of the
popliteal artery, narrowing or slight angulation, and
sometimes poststenotic dilatation. Transient partial
lesions of the popliteal artery wall, with absence of
lesions at other levels, are certainly reason for suspi-
cion of PAES. When suspected, PAES can be estab-
lished by dynamic arteriography with runoff during
stress, performed with the patient’s leg in hyperex-
tension. Deviation (medial or lateral) and occlusion
of the proximal popliteal artery with extended knee
confirms the diagnosis of popliteal entrapment.
When entrapment has produced popliteal artery
occlusion, positional maneuvers will not, of course,
aid diagnosis. Complete obstruction of the popliteal
artery in the presence of large collateral arteries and
normal proximal and distal arteries is usually seen in
later stages of PAES.
It is well known that conventional plain film arte-
riography often leads to overestimation of the length
of occluded vessel segments, a phenomenon that may
be caused by dilution of the bolus of contrast materi-
al as it traverses segmental occlusions or stenosis be-
tween the site of injection and the distal target.
Volume 27, Number 1, 2000
 When DSA is used, overestimation should not
occur, because the acquisition series are not stopped
until there is no further filling of arteries. Digital
subtraction angiography is well suited for the detec-
tion of slow flow and retrograde flow. The length of
the popliteal occlusion and the degree of refilling via
collateral vessels are important in planning therapy
for patients with late-phase PAES. In the preopera-
tive work-up of patients with severe occlusive PAES,
the identification of patent runoff vessels is crucial.
The use of the digital subtraction technique has
overcome the problem of bone superimposition. At
our institution, it is standard practice to obtain mul-
tiple comparative series of popliteal artery studies for
functional diagnosis of entrapment. 64-68 In doing this,
we perform intraarterial digital subtraction angiog-
raphy of the lower extremities in combination with
Doppler ultrasonographic examination and comput-
ed tomographic angiography.
In symptomatic cases of PAES, surgery is definite-
ly indicated in order to establish normal anatomy
within the popliteal space and restore normal arterial
flow to the extremity. The best surgical approach is
a posterior S-shaped incision in the popliteal fossa,
which enables complete exposure of the popliteal
artery and its surrounding structures. Although the
medial approach yields better exposure of the super-
ficial femoral and tibial arteries, it does not enable
identification of the structures around the popliteal
artery and confers, therefore, a high risk of incom-
plete section of the musculotendinous structures
causing the entrapment. When the diagnosis of en-
trapment is made at an early stage and the popliteal
artery is intact, the treatment of choice is the release
of the popliteal artery by division of the anomalous
musculotendinous tissue. If the diagnosis is made
later, when the popliteal artery is occluded, stenotic,
or aneurysmal, the treatment of choice is vascular
reconstruction, in addition to division of the anom-
alous musculotendinous structure.
Thromboendarterectomy is difficult to perform
in the entrapped segment of popliteal artery, because
no plane of cleavage exists in the wall of the fi-
brous, cord-like artery. If decompression of the
popliteal artery by division of the anomalous muscle
is not in itself adequate, the interposition of autolo-
gous vein graft is also necessary. This is usually a
popliteo-popliteal bypass, kept as short as possible.
Our material of choice is usually the contralateral
long saphenous vein.25,69,70 The ipsilateral long and
short saphenous veins are usually spared, because of
their importance in this area, in which the circula-
tion already has been compromised.
Texas Heart Institute Journal
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Texas Heart Institute Journal Popliteal Artery Entrapment Syndrome 13